Corporate

Medical Policies

Coverage for services under Medicare is primarily established through the Social Security Act. Provisions of the Social Security Act are applied to specific services based on various regulations, National Coverage Determinations established by the Centers for Medicare & Medicaid Services (CMS), various CMS guidelines, and Local Coverage Determinations (LCDs) established by CGS.

  • NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service.
  • LCDs are developed by Medicare Administrative Contractors (MACs), including CGS, and indicate whether a particular item or service is covered in accordance with the Social Security Act, section 1862(a)(1)(A). (See list of LCDs below.)
  • NCDs and LCDs only address certain services and items; in other words, not every item or service has a corresponding NCD or LCD. In these cases, the Social Security Act, and in some cases, additional guidance published by CMS, establish the basis for coverage.
  • For more information about NCDs, LCDs, and other coverage provisions, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 13External PDF.
  • CAC, Compliance and Open Public Meeting

IMPORTANT NOTE: CGS does NOT house LCDs on our website. By following the links below you will be sent directly to the CMS LCD database.

The following CGS Part A Local Coverage Determinations (LCDs) are located on the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database (MCD) webpage. CMS also provides the LCD Contractor IndexExternal Website, where providers can browse LCDs by contractor.

ID Title Effective Date Revision Effective Date Last Updated Status HCPC/CPT code
L32553External Website Allergy Immunotherapy 10/1/2015 10/1/2015 10/30/2017 Active 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180, 95199
L33943External Website B-type Natriuretic Peptide (BNP) Testing 10/1/2015 10/1/2015 11/28/2017 Active 83880
L33944External Website Blepharoplasty 10/1/2015 10/1/2015 10/30/2017 Active 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924,

Group 2 Codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908
L33945External Website Cerumen (Earwax) Removal 10/1/2015 1/1/2016 1/30/2018 Active 69209, 69210, G0268
L33946External Website Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy 10/1/2015 10/1/2015 10/30/2017 Active 66820, 66821
L33947External Website Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 10/1/2015 10/1/2016 10/30/2017 Active 75571, 75572, 75573, 75574
L33949External Website Botulinum Toxins 10/1/2015 10/1/2015 11/28/2017 Active Group 1 Codes: 43201, 43236, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345,

Group 2 Codes: C9399, J0585, J0586, J0587, J0588, J3590
L33950External Website Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography 10/1/2015 1/1/2018 12/14/2017 Active 19030, 76641, 76642, 77053, 77054, 77058, 77059, 77063, 77065, 77066, 77067, C8903, C8904, C8905, C8906, C8907, C8908, G0279
L33952External Website Cardiac Event Detection 10/1/2015 10/1/2015 10/30/2017 Active 93228, 93229, 93268, 93270, 93271, 93272, 93799
L33954External Website Cataract Extraction 10/1/2015 10/1/2016 12/21/2017 Active 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
L33959External Website Cardiac Catheterization and Coronary Angiography 10/1/2015 1/1/2018 12/18/2017 Active Group 1: 92978, 92979, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93462, 93463, 93464, 93503, 93505, 93530, 93531, 93532, 93533, 93561, 93562, 93563, 93564, 93565, 93566, 93567, 93568, 93571, 93572, G0269

Group 2 Codes: 36140, 36200, 36215, 36216, 36217, 36218, 36221, 36222, 36223, 36224, 36225, 36226, 36227, 36228, 36245, 36246, 36247, 36248, 75625, 75630, 75635, 75705, 75710, 75716,

Group 3 Codes: G0278
L33960External Website Cardiovascular Nuclear Medicine 10/1/2015 10/1/2015 1/30/2018 Active 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 93015,93016, 93017, 93018, A9500, A9501, A9502, A9505, A9512, A9538,A9560, J0153, J1245, J1250, J2785, J3490
L33996External Website Vitamin D Assay Testing 10/1/2015 5/1/2017 7/5/2017 Active 82306
L33999External Website Corneal Pachymetry 10/1/2015 10/1/2016 1/30/2018 Active 76514
L34005External Website Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy 10/1/2015 10/1/2017 1/30/2018 Active 44388, 44389, 44390,44391, 44392, 44394, 44401, 44402, 45300, 45303, 45305, 45307, 45308, 45309, 45315, 45317, 45320, 45321, 45327, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45378, 45379, 45380, 45381, 45382, 45384. 45385, 45386, 45388, 45389, 45391, 45392, 45399
L34008External Website Computerized Corneal Topography 10/1/2015 5/1/2018 5/9/2018 Active 92025
L34032External Website Debridement Services 10/1/2015 10/1/2017 1/30/2018 Active 11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047
L34037External Website Flow Cytometry 10/1/2015 10/1/2017 2/26/2018 Active 86355, 86356, 86357, 86359, 86360, 86361, 86367, 88182, 88184, 88185, 88187, 88188, 88189
L34045External Website Non-Invasive Vascular Studies 10/1/2015 3/1/2018 3/2/2018 Active Group 1 Codes: 93880 93882 93886 93888 93890 93892 93893

Group 2 Codes: 93922 93923 93924 93925 93926 93930 93931

Group 3 Codes: 93970 93971

Group 4 Codes: 93975 93976 93978 93979

Group 5 Codes: 93990 G0365 
L34046External Website Speech-Language Pathology 10/1/2015 1/1/2018 12/18/2017 Active 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96111, 96125, 97533, G0515
L34048External Website Vertebroplasty and Vertebral Augmentation (Percutaneous) 10/1/2015 10/1/2015 9/29/2016 Active 22510, 22511, 22512, 22513, 22514, 22515,76380
L34049External Website Outpatient Physical and Occupational Therapy Services 10/1/2015 1/1/2018 5/31/2018 Active 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29240 29260 29280 29345 29355 29365 29405 29425 29445 29505 29515 29520 29530 29540 29550 29580 29799 90901 90911 95831 95832 95833 95834 95851 95852 96125 97010 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97161 97162 97163 97164 97165 97166 97167 97168 97530 97533 97535 97537 97542 97597 97598 97602 97605 97606 97607 97608 97750 97755 97760 97761 97763 97799 G0281 G0283 G0329 G0515
L34055External Website Virtual Colonoscopy (CT Colonography) 10/1/2015 10/1/2017 9/14/2017 Active 74261, 74262
L34056External Website Urodynamics 10/1/2015 10/1/2016 9/29/2016 Active 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797
L34061External Website Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 10/1/2015 10/1/2017 10/3/2017 Active 92133, 92134
L34062External Website Dialysis Access Maintenance 10/1/2015 1/1/2018 1/30/2018 Active 36005, 36010, 36140, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36593, 36831, 36832, 36833, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 37186, 37211, 37212, 37213, 37214, 37236, 37237, 37246, 37247, 37248, 37249, 75710, 75820, 75822, 75825, 75827, 93990
L34063External Website RAST Type Tests 10/1/2015 10/1/2015 7/25/2016 Active 86001, 86003, 86005
L34064External Website Panretinal (Scatter) Laser Photocoagulation 10/1/2015 10/1/2016 2/26/2018 Active 67228
L34081External Website Endoscopy by Capsule 10/1/2015 10/1/2017 2/26/2018 Active 91110, 91111, 91299
L34082External Website Varicose Veins of the Lower Extremity, Treatment of 10/1/2015 1/1/2018 3/6/2018 Active 36468, 36470, 36471, 36475, 36476, 36478, 36479, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799, 76942, 93970, 93971
L34084External Website Transcatheter Infusion Therapy 10/1/2015 10/1/2016 8/28/2017 Active 61650, 61651
L34085External Website Post-Void Residual Urine and/or Bladder Capacity by Ultrasound 10/1/2015 10/1/2016 2/26/2018 Active 51798
L34087External Website Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based 10/1/2015 10/1/2015 10/4/2017 Active 93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296
L34089External Website Human Papillomavirus (HPV) Testing 10/1/2015 10/1/2015 3/28/2018 Active 87623, 87624
L34090External Website Laser Ablation of the Prostate 10/1/2015 10/1/2015 3/28/2018 Active 52647, 52648, 52649
L34093External Website Chemotherapy and Biologicals 10/1/2015 5/25/2018 6/20/2018 Active N/A
L34171External Website Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation 10/1/2015 10/1/2015 5/31/2018 Active 68801 68810 68811 68815 68816 68840 
L34175External Website Ophthalmic Angiography (Fluorescein and Indocyanine Green) 10/1/2015 10/1/2016 5/31/2018 Active 92235 92240
L34181External Website Ophthalmic Biometry for Intraocular Lens Power Calculation 10/1/2015 10/1/2016 5/31/2018 Active 76519 92136
L34183External Website Psychiatric Inpatient Hospitalization 10/1/2015 10/1/2016 2/26/2018 Active N/A
L34195External Website Mohs Micrographic Surgery 10/1/2015 3/1/2017 4/30/2018 Active 17311, 17312, 17313, 17314, 17315
L34196External Website Psychiatric Partial Hospitalization Programs 10/1/2015 10/1/2016 2/26/2018 Active 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899, 96101, 96102, 96103, 96116, 96118, 96119, 96120,G0129,G0176, G0177, G0410, G0411
L34200External Website Removal of Benign Skin Lesions 10/1/2015 11/1/2017 11/27/2017 Active 11200, 11201,11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403,11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442,1 1443, 11444, 11446, 17000, 17003, 17004, 17106, 17107, 17108, 17110, 17111, 17340
L34246External Website Routine Foot Care and Debridement of Nails 10/1/2015 10/1/2017 9/15/2017 Active 11055, 11056, 11057, 11719, 11720, 11721, G0127
L34337External Website Transesophageal Echocardiography (TEE) 10/1/2015 11/27/2017 11/27/2017 Active 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927
L34338External Website Transthoracic Echocardiography (TTE) 10/1/2015 10/1/2017 9/15/2017 Active Group 1 Codes: 76376, 76377, 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, 93352, A9700, C8921, C8922, C8923, C8924, C8928, C8929, C8930, Q9955, Q9956, Q9957

Group 2 Codes: C9399, J0153, J0280, J0461, J1245, J1250, J2785, J3490
L34353External Website Outpatient Psychiatry and Psychology Services 10/1/2015 10/1/2016 5/31/2018 Active 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90865, 90870, 90880, 90885, 90887, 90899, 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120
L34356External Website Erythropoiesis Stimulating Agents (ESA) 10/1/2015 10/1/2017 2/26/2018 Active J0881, J0882, J0885, J0890, Q4081
L34370External Website Category III CPT® Codes 10/1/2015 3/18/2018 2/26/2018 Active N/A
L34393External Website Ocular Photography - External 10/1/2015 10/1/2015 4/30/2018 Active 92285
L34394External Website Visual Fields Testing 10/1/2015 10/1/2017 9/15/2017 Active 92081, 92082, 92083
L34399External Website Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 10/1/2015 10/1/2017 5/31/2018 Active 92225 92226 92227 92228 92250
L34539External Website Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians 10/1/2015 10/1/2015 2/26/2018 Active 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90863, 90880, 90899
L34540External Website Stretta Procedure 10/1/2015 10/1/2015 8/28/2017 Active 43257
L34541External Website Transtelephonic Spirometry 10/1/2015 10/1/2015 9/29/2016 Active 94014, 94015, 94016
L34807External Website Lumbar Epidural Steroid Injections (ESI) 10/1/2015 10/1/2017 12/21/2017 Active 62323, 62327, 64483, 64484,
L34832External Website Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 10/1/2015 10/1/2016 12/21/2017 Active 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636
L35249External Website Nerve Blocks for Peripheral Neuropathy 10/1/2015 10/1/2015 4/30/2018 Active 64450 76881 76882 76942 76999 97032 97139 G0282 G0283
L35332External Website MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 10/1/2015 10/1/2017 12/22/2017 Active 81225, 81226, 81227, 81355, 81479
L35349External Website MolDX: Genetic Testing for Lynch Syndrome 10/1/2015 10/13/2016 10/30/2017 Active Group 1: 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81403, 81435, 81479

Group 2: 81445, 81455
L35442External Website MolDX: NRAS Genetic Testing 10/1/2015 1/19/2017 2/7/2017 Active 81311, 81479
L35443External Website MolDX: GeneSight ® Assay for Refractory Depression 10/1/2015 3/8/2018 5/23/2018 Active 81479
L35891External Website Intravenous Immune Globulin 10/1/2015 3/1/2018 3/28/2018 Active J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, 
L35897External Website Nerve Conduction Studies and Electromyography 10/1/2015 10/1/2017 4/30/2018 Active 51785 92265 95860 95861 95863 95864 95865 95866 95867 95868 95869 95870 95872 95873 95874 95885 95886 95887 95905 95907 95908 95909 95910 95911 95912 95913 95933 95937 95999 G0255
L35906External Website Somatosensory Testing 10/1/2015 10/1/2017 3/28/2018 Active 95925, 95926, 95927, 95928
L35984External Website MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 10/1/2015 12/31/2015 6/27/2016 Active 81240, 81241, 81291
L35986External Website Special Histochemical Stains and Immunohistochemical Stains 10/1/2015 8/31/2017 8/23/2017 Active 88312, 88313, 88341, 88342, 88344, 88360, 88361
L36002External Website MolDX: Prolaris™ Prostate Cancer Genomic Assay 10/5/2015 1/1/2018 4/4/2018 Active 81479
L36006External Website MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay 10/5/2015 1/1/2018 12/13/2017 Active 81551
L36011External Website MolDX: Molecular RBC Phenotyping 10/5/2015 1/1/2018 12/13/2017 Active 0001U
L36021External Website Molecular Diagnostic Tests (MDT) 10/1/2015 4/5/2018 4/4/2018 Active 81161 81162 81170 81175 81176 81200 81201 81202 81203 81205 81206 81207 81208 81209 81210 81211 81212 81213 81214 81215 81216 81217 81218 81219 81220 81221 81222 81223 81224 81225 81226 81227 81228 81229 81230 81231 81232 81235 81238 81240 81241 81242 81243 81244 81245 81246 81247 81248 81249 81250 81251 81252 81253 81254 81255 81256 81257 81258 81259 81260 81261 81262 81263 81264 81265 81266 81267 81268 81269 81270 81272 81273 81275 81276 81283 81287 81288 81290 81291 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81302 81303 81304 81310 81311 81313 81314 81315 81316 81317 81318 81319 81321 81322 81323 81324 81325 81326 81327 81328 81330 81331 81332 81334 81335 81340 81341 81342 81346 81350 81355 81361 81362 81363 81364 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81400 81401 81402 81403 81404 81405 81406 81407 81408 81410 81411 81412 81413 81414 81415 81416 81417 81420 81422 81425 81426 81427 81430 81431 81432 81433 81434 81435 81436 81437 81438 81439 81440 81442 81445 81448 81450 81455 81460 81465 81470 81471 81479 81490 81493 81500 81503 81504 81506 81507 81508 81509 81510 81511 81512 81519 81520 81521 81525 81528 81535 81536 81538 81539 81540 81541 81545 81551 81595 81599 84999 85999 86849 87999 88199 88299 88380 88381 88399 89398 G0452 0001M 0002M 0003M 0004M 0006M 0007M 0008M 0009M
L36029External Website Controlled Substance Monitoring and Drugs of Abuse Testing 10/5/2015 10/1/2017 4/4/2018 Active 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659
L36048External Website MolDX: HLA-B*15:02 Genetic Testing 10/5/2015 10/5/2015 5/31/2018 Active 81381
L36113External Website MolDX: MGMT Promoter Methylation Analysis 10/5/2015 10/5/2017 5/31/2018 Active 81287
L36117External Website MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 10/5/2015 10/5/2017 11/2/2017 Active 81206, 81207, 81208, 81219, 81270, 81402, 81403, 81445, 81450, 81455, 81479
L36139External Website MolDX: Biomarkers in Cardiovascular Risk Assessment 10/5/2015 10/1/2016 9/23/2016 Active 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83719, 83721, 86141
L36174External Website MolDX: NSCLC, Comprehensive Genomic Profile Testing 10/1/2015 10/5/2017 12/22/2017 Active 81445, 81455, 81479
L36206External Website MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 10/5/2015 1/1/2018 5/31/2018 Active 81479
L36425External Website MolDX: Breast Cancer Assay: Prosigna 2/1/2016 1/1/2018 12/13/2017 Active 81520
L36456External Website MolDX: BRCA1 and BRCA2 Genetic Testing 2/15/2016 11/1/2017 12/22/2017 Active 81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81445, 81455, 81479
L36458External Website MolDX: Breast Cancer Index℠ Genetic Assay 2/1/2016 2/1/2016 6/27/2016 Active 81479
L36460External Website Bone Mass Measurement 2/1/2016 3/1/2018 5/7/2018 Active 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130
L36469External Website Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 2/8/2016 2/8/2016 12/21/2017 Active 90867, 90868, 90869
L36485External Website MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 2/15/2016 3/6/2017 12/21/2017 Active 81383
L36494External Website Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 2/1/2016 2/1/2016 12/21/2017 Active 27279
L36656External Website MolDX: Decipher® Prostate Cancer Classifier Assay 10/10/2016 3/8/2018 5/23/2018 Active 81479
L36658External Website Proton Beam Therapy 10/24/2016 8/28/2017 8/28/2017 Active 77520, 77522, 77523, 77525 
L36675External Website MolDX- CDD: ProMark Risk Score 10/10/2016 10/17/2017 11/2/2017 Active 81479
L36690External Website Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities 10/10/2016 1/1/2018 5/25/2018 Active Group 1 Codes: 15002, 15003, 15004, 15005, 15040, 15050, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278

Group 2 Codes: Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, Q4131, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4140, Q4141, Q4146, Q4147, Q4148, Q4151, Q4152, Q4153, Q4154, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4163, Q4164, Q4165, Q4169, Q4172, Q4173, Q4174, Q4175
L36902External Website Polysomnography and Other Sleep Studies 3/6/2017 3/6/2017 1/30/2018 Active Group 1 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400

Group 2 95803
L36906External Website GlycoMark Testing for Glycemic Control 3/6/2017 3/6/2017 4/4/2018 Active 84378, 84999
L36908External Website MolDX: Percepta© Bronchial Genomic Classifier 3/13/2017 7/20/2017 7/28/2017 Active 81479
L36910External Website MolDX: APC and MUTYH Gene Testing 3/13/2017 3/8/2018 4/4/2018 Active 81201, 81202, 81203, 81403, 81406, 81435, 81479
L36951External Website MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 3/6/2017 7/20/2017 7/24/2017 Active 81479
L36973External Website MolDX: Circulating Tumor Cell Marker Assays 3/6/2017 7/20/2017 3/28/2018 Active 86152, 86153
L36975External Website Bladder/Urothelial Tumor Markers 3/6/2017 3/23/2017 1/30/2018 Active 86294, 86316,86386, 88120 ,88121
L36979External Website MolDX: 4Kscore Assay 3/13/2017 N/A 1/18/2017 Active 81539
L37126External Website Coenzyme Q10 (CoQ10) 7/10/2017 7/10/2017 5/31/2018 Active N/A
L37130External Website MolDX: DecisionDx-UM (Uveal Melanoma) 7/10/2017 7/20/2017 5/31/2018 Active 81599
L37134External Website MolDX: Xpresys Lung 7/10/2017 7/13/2017 5/31/2018 Active 81599
L37142External Website MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 7/10/2017 1/1/2018 5/31/2018 Active 81541
L37254External Website Chiropractic Services 11/6/2017 1/16/2018 N/A Active 98940, 98941, 98942
L37352External Website MolDX: Prometheus IBD sgi Diagnostic Policy 11/6/2017 3/8/2018 1/12/2018 Active 81479, 82397, 83520, 86140
L37354External Website MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 3/6/2018 N/A N/A Active 81479
L37356External Website MolDX: EndoPredict Breast Cancer Gene Expression Test 3/6/2018 N/A 1/12/2018 Active 81599
L37362External Website MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 3/6/2018 N/A 1/12/2018 Active 81479
L37578External Website Micro-Invasive Glaucoma Surgery (MIGS) 3/19/2018 3/19/2018 1/26/2018 Active 0191T, 0449T, 0450T, 0474T, 0376T

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